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  1. “TURF WARS”Episode IVA NEW HOPE This is a time of many readmissions, some for reasons that could have been prevented by the hospitalist staff. Many, however can be better managed with triage to appropriate services, perhaps even in the outpatient setting…

  2. INDEX ADMISSION • Admitted for a questionable cause… • Family utilizes admission as a way to transition to nursing facility

  3. “N.T” a seventy five year old AAF with hemophila A and history of oropharyngealsquamous cell CA dx 2008 s/p chemo/radiation/surgical excision now with laryngectomy and stoma. • Originally admitted to me 1/17/11 for monitoring of hemophila A one day prior to esophageal stent removal. Stent placed in 12/2010 for dysphagia/esophageal stricture • Seen 1/13 by Dr Field, Factor VIII level activity at 156% and PTT in normal range. NO FACTOR WAS INFUSED, and while level was rechecked, results are never available same day.

  4. During inpatient stay, virtually no treatments are administered that require inpatient stay • When patient is ready for discharge, daughter suddenly brings up concerns that she feels unable to take care of patient any longer, and pt is unsafe at home. She states she has communicated this to patient’s outpatient physicians to no avail • Patient accepted by facility and was sent to SNF 2/24/11

  5. Several Readmissions Follow • Patient requires very specialized care for which her daughter had been educated • SNF poorly equipped to deal with specialized care that this patient is in need of • There seems to be a disconnect in communication, or a lack of willingness of the SNF to “try” to avoid readmission

  6. Patient seems to be sent to ER frequently for various reasons… • The patient is brought back to ER within days from nursing home for nausea and vomiting, which are documented in the discharge summary as occurring frequently in this patient due to overeating. Pt discharged back to SNF • Patient readmitted 2/28-2/29 for respiratory distress due to stoma manipulation and only intervention was stoma revision and stent placement by ENT

  7. More visits to ER… • Pt comes back to ED 2/2 for “laryngectomy prosthesis that is dislodged, unable to reinsert at the Care Center, center is requesting more instructions on this prosthesis if sent back” per ED notes. • Pt back in ED 2/5 for sudden hematemesis, sent to MICU then to floor after ENT placed longer tube in stoma. This admission unavoidable • Pt back in ED 2/17 for same

  8. Potential Solutions? • Better communication between SNF, daughter and specialists (ENT, GI) • Avoiding utilization of the hospital as path of least resistance • Direct communication of staff with SNF about anticipated problems and ‘what to do if…’

  9. A Happy Endingfor now… • Next admission was planned for PEG tube replacement in 3/09(which daughter was requesting since Jan) • Then another planned admission for EGD 3/21 • After this her procedures have been done in outpatient, which seems most appropriate.

  10. Why should we change? • Health care reform will require focused efforts to improve care for the 10% of patients who account for 64% of all U.S. health care costs, such as this patient • The future of medicine in the US may see hospitalization become the path of greatest resistance, instead of the path of least resistance, as it is now.